North Durham Primary Care Strategy Implementation Plan Background and scope The North Durham Primary Care Strategy was shared with Practice members in July 2015. The following is a draft implementation plan identifying the programme of key work streams in which to take it forward. In drawing up this implementation plan it is important to acknowledge that the Primary Care Strategy forms the basis of an overall integrated strategy for Out of Hospital Care. The Vision To develop a fit for purpose workforce and infrastructure to deliver Care closer to home To support General Practice to work with each other and with local people to deliver high quality, cost effective Primary Care To commission clinically effective planned and unplanned out of hospital care To deliver that vision the CCG has 5 key strategic objectives for Primary Care 1. To have high quality care services supporting 7 day working with additional capacity to support an out of hospital strategy 2. To have a service that strengthens the prevention and management of long term conditions 3. To have a service that co-ordinates the care for our most vulnerable patients eg The frail elderly and the dying 4. To secure quality of Primary Care Services and reduce variation 5. To involve Primary Care in a systematic approach to health improvement To deliver these objectives, we believe that a stronger GP sector must have the following key features: Maintains the strengths of General Practice in terms of personalised, continuity of care to a registered population, when necessary Builds organisational capacity within General Practice at Locality level and an infrastructure to enable Cross Practice working Is bigger, wider and integrates seamlessly with social and community services Is aligned and works in partnership with Public Health Enables patients to feel engaged in their care Provides a rewarding and enjoyable place to work, enabling adequate recruitment and retention for sustainable services
To bring about these changes, the CCG will focus on the following initiatives to provide integrated services based on new operating models at Locality level. This will be supported by enabling workstreams that help to build the infrastructure of Primary Care in those Localities. Service Developments 1. Moving towards 7 day working and extending access to Primary Care 2. Developing a new model of care for Diabetes 3. Developing integrated services for the Frail elderly and dying 4. Driving up quality across Practices through a Quality Improvement strategy 5. Identifying and implementing a key role for Primary Care aligned to the Public Health agenda (Health and Wellbeing strategy) Infrastructure Developments 1. Building organisational capacity through the support and development of Federations and scaled up General Practice 2. Creating opportunities for increased capacity and development of the Primary Care workforce, including better integration with Community staff 3. Supporting IT development to find solutions that make services more accessible and joined up 4. Develops an Estates strategy that makes the most of current estate and looks for opportunities to develop the Estate to deliver the new service models The remainder of this document looks firstly at the operating model of Locality working which forms the basis of our Out of Hospital Care strategy in all our workstreams. It then takes each individual area and identifies the progress made so far and the work that needs to be done to take it forward. Key to taking it forward is the continued engagement with patients, practices and other providers in building on the model and finding new solutions to old problems.
Key features of a new operating model for Out of Hospital Care Out of hospital care will be delivered and co-ordinated at locality level. Local Practice Teams to provide continuity to their registered population supported by aligned community services consisting of designated District Nurses and Community Matrons to each locality. Hubs within each locality to provide supporting services across Practices in each Locality. This may consist of specialist clinical, specialist nursing, diagnostic, outreach, rehabilitation, out of hours services or even shared core GP services. Key elements at this level are : Cross practice working eg Out of hours services Integration between social and community services, eg Intermediate Care + (IC+) services Vertical integration between Acute, Community and General Practice services. Eg Diabetic clinics These hubs may be based at specified practices or community locations depending on the PC and community estate or historical agreements at locality level, hence the importance of an estates strategy to follow the service strategy.
Continuity of information through effective IT solutions is imperative to enable access to a single patient record where possible and effective working across practices and community services. A co-ordinated approach to improving health and wellbeing can be planned, contracted and integrated at practice or community level wherever is best accessible for patients. Federations (or other models of scaled up General Practice at Locality level) will be perfectly placed to take the lead for some, or all, of these services, either providing them as a Provider organisation themselves, or working with other Organisations within a Multi-speciality Care provider model. Service Developments Moving towards 7 day working and extended access to Primary Care Update A review of Urgent Care services and out of hours services is underway with notice given to the existing Provider (CDDFT) of the CCG s plan to re-procure the Out of hours element with an updated service specification. This will require a disaggregation of the contract between North and South Durham to identify the financial envelope to re-invest in a model going forward. In line with Government policy, there is a drive to move towards 7 day working and extended weekday working as part of the core GP contract. The Prime Minister has recently announced a new voluntary GP contract that will be in place by April 2017 that requires GP opening from 8am to 8pm during both weekdays and weekends. The detail of this is not yet available but it will be delivered and contracted for through Federations enabling new models of working across practices in geographical localities. The timescale to define a new model of working and contract for its implementation is by April 2017 when the first examples of new models will go live. In addition to this the new Vanguard project across the North East and Yorkshire will drive initiatives as to how locality models of urgent care services integrates with a cross region model of working. For example: o Central data collection and monitoring of demand o Better self care and education of use of services o Future use of 111 as a point of access for urgent care or advice, including availability of GP appointments o Integration with ambulance and paramedic services
o Fewer, but more specialised centres of Accident and Emergency care through new payment models o More accessible integrated care out of hospital service at a Locality level Next steps 1. There is a CCG working group set up to take forward the Urgent Care strategy which will co-ordinate its implementation going forward, anticipating the key role Urgent Care will play in a wider Out of hospital strategy in each Locality. 2. The CCG will work with each Federation (as part of their Organisational Development plan) to define a model of 7 day working for General Practice in each Locality which will describe aspects of how that service may be provided. Where, when, how, who 3. Consult with patients and the public about emerging models of access to 7 day services at locality level. 4. Work with other Providers as to how this integrates with other 7 day working strategies eg Community Matrons, IC+ services, diagnostics, new consultant contracts, A&E services. 5. Understand the financial framework (from disaggregation of the Out of Hours contract) and new Commissioning routes (new GP contract model, or Vanguard sites) that we can use to drive and implement new models of 7 day working. 6. Work with the System Resilience Group to understand the implications of the North East and Yorkshire Regional Vanguard initiatives. 7. Engagement with Practices, Federations and the Constituency leads is now paramount in how General Practice will work within this model to find an effective solution. Implementing a new model of Care for Diabetes Update A multidisciplinary working group has been working over the last 18 months to define a new locality model of working and the CCG has invested 450,000 in its implementation
The model is based around secondary and primary care, with supporting services, working together at a locality level to manage a defined cohort of patients Each locality will have a consultant lead, a specialist nurse and work with individual practices and their clinical leads either in practices or at locality hubs which are accessible for the patients The model will involve an integrated approach to prevention, diagnosis, surveillance, and intervention The model will also introduce new models of commissioning diabetes care and allocation of funds at practice / locality level Next steps A Diabetes Governance Board is being set up to oversee the implementation across 7 Locality Groups in Co Durham (3 for North Durham) by Dec 2015 Each group will : o Map out the baselines of care in each of their Localities, including registers, skills base, outcomes/current performance and patient cohort profile o Identify its priorities based on savings targets, practice baselines and investment allocations o Submit Practice investment proposals, via the Governance Board, to each CCG for approval Investment will be allocated to individual Practices, or Federations, according to agreed criteria The next 6 months to April 2016 will focus on: Creation of a prevention investment plan, with Durham County Council, to align at all levels of the model Further education and ownership of the model at locality level. Prescribing campaign launched Benchmarking of Practice baselines Setting up Diabetic Groups at each Locality level with agreed representation from the Practices (or Federation). Creating a plan for transition of current services for April 2016 going forward Implementing integrated services for the Frail Elderly Update The model for the frail elderly has been developed at 4 different levels of care that together form an integrated pathway for the frail elderly patient. Its implantation is already well under way the elements of which will all be in place by early 2016.
Four levels of Care 1. Prevention and wellbeing Public health and the Health and Wellbeing Board working on a strategy to reduce social isolation. 2. Practice level Primary Care identifying a register of the Frail Elderly in each practice using agreed search criteria as a case finding tool. Each Practice being contracted to assess all patients on this register in terms of frailty, risk of falls, cognitive assessment and medication review. Each patient to have an Advanced Care Plan / Emergency Health Care Plan by March 2016. According to need, to provide targeted proactive and reactive care using a case management approach on a multidisciplinary team basis where required. 3. Locality based services At Federation level, working across Practices to provide a weekend GP service to support those on the Frail Elderly register, and those in care Homes, providing reactive and proactive care alongside Community Matrons, to keep this vulnerable cohort of patients out of hospital or facilitate discharge where necessary. Community Services and Care Home provision o District Nurses are now aligned to specific Practices and specific Care homes o Investment in Community Matron capacity with CDDFT to align with existing District Nursing teams in Care Homes o Re-align named Practices to specific Care Homes to complete a clinical support team of GP, District nurse and Community Matron to each Care Home in a Locality o All Care homes to have completed Emergency health Care Plans for each resident by March 2016 After April 2016 onwards Full alignment of District Nurses to Practices and Care Homes, providing a range of proactive and reactive care on a case management basis, with integration of Community Matrons working at Practice level to a register of frail elderly patients both in Care homes and at their own homes. Locality based Multidisciplinary Intermediate Care Services The IC+ Intermediate Care Plus o Integrated support from specialist nurses, rehab teams and access to carer support, provided from a Single Point of Access (SPA)
o This is now in place, allowing urgent intervention in a co-ordinated approach. This can arise from either a step up referral from the community, or a step down referral from hospital o The service provides rapid access to an appropriate level of support to keep people out of hospital or facilitate discharge o It is available 7 days a week, 24 hours per day 4. Linking with Specialised Elderly care Services Rapid Assessment Clinics o Daily Clinics Monday to Friday to provide same day / next day appointments for urgent medical assessments o Access via Single Point of Access service o Locations at Shotley Bridge and Chester le Street Community Hospitals o Providing full elderly assessment, access to diagnostics, therapy, medical opinion and onward referral if necessary Consultant Advice lines Daily 12-2 pm Proposed Front of House Service working alongside A+E at UHND to provide a consultant led service, providing urgent assessment to the frail elderly attending A&E, including diagnostics, access to therapy and IC+ services This will be integrated with other Community support services described above through shared access to Community service and Social Service IT systems Driving up Quality of Primary Care Services and reducing variation Working with NHS England Area Team to: 1. Report Primary Quality using The Primary Care Web Tool 2. Improve reporting of serious incidents in Primary Care 3. Reduce variation of quality across Primary care 4. Ensure dissemination and uptake of NICE guidelines 5. Implement a Programme of audit work for quality improvement in specific areas 6. Review processes for improving quality in referral pathways
7. Improve use of GP Teamnet across North Durham as an information management tool to enable dissemination of : a. Updates, information and diary events b. NICE guidelines c. Clinical support information (CSI) guidelines d. Medicines optimisation guidelines and newsletters e. GP appraisal documentation. 8. Improve quality of prescribing through the prescribing incentive scheme and the Medicines Optimisation programme. 9. Explore potential for re-instigating the Quality Improvement Scheme at Practice level to re-engage Practices in areas of Quality Improvement. (See Quality Improvement strategy update ) Introducing a systematic approach to Health Improvement 1. To work with Public Health and Federations to explore how Primary Care can work contribute to the Health improvement programme to provide solutions to reduce social isolation. 2. Work on Lifestyle schemes to reduce: a. Smoking b. Obesity c. Cardiovascular risk through patient health checks d. Low exercise rates e. Mental illness 3. Improve self-management schemes for people with Long term conditions 4. Increasing screening and vaccination rates 5. Reducing Health inequalities and causes of ill health.
Developing the Primary Care infrastructure Building organisational capacity through Federations 1. In North Durham we have 3 Federations based around 3 distinct geographical Localities: Chester le Street 6 Practices approx. 60,000 patients Durham 8 Practices approx. 100,000 patients Derwentside 15 Practices approx. 95,000 patients Each area historically are used to working well with each other. 2. They are currently supported and resourced by the CCG through contracts to: a. Develop an Organisational Development Plan to set up themselves as legal entities, Governance arrangements, capacity and a Business plan b. To set up a weekend on call service for the Frail elderly c. To identify other examples of Cross Practice working d. To deliver an example of Multi-speciality Care provision 3. Progress update. All 3 Organisations are now set up as legal entities Each will have completed an Organisational Development plan template to show progress after 6 months in existence (by end of October) To date, the Weekend on call service of the elderly has only been set up in one locality. (Chester-le-Street) Both others are keen to proceed but have been delayed due to CQC registration delays 4. Comments Federation development is still in its infancy although each shows potential Whilst gaining the support and credibility of their member Practices it is also important for the CCG that they become engaged with the objectives of the Primary Care strategy and we have an early success in what they can deliver
Creating opportunities for the Primary Care Workforce 1. PC Strategy group to oversee initiatives. 2. Work with HENE and the Federations to develop workforce plans for Practice Nurses and GP in each Locality, including a survey to understand the current situation and the position 5yrs from now to identify risks and potential gaps. 3. Work is in progress to set up a CCG funded Career Start scheme for GP s recruiting 5 new GP s to the area to work in designated Practices with GP mentor support. This is in addition to the continuing Career Start scheme for Practice Nurses which is an ongoing success at attracting more Practice Nurses onto a training and recruitment programme across Co Durham. 4. Explore other potential initiatives with HENE and other CCG s for recruitment, retention and use of other primary care professionals for alternative access to care. Eg Community Matrons and clinical pharmacists 5. An Education and Training steering group with an approved budget has been set up, bringing together GP tutors, Practice Nurse tutors and Locality representatives to develop a menu of education and training events that supports Primary Care professionals and their teams. This will include mandatory training such as Safeguarding adults and children training events, and GP and Practice Nurse Update courses 6. Continuing Protected Learning times for practices, but aligning them to the same 3 rd Thursday afternoon each month across all Localities. This provides protected time for Practices and individuals to focus on key areas of education. By aligning the timing of the PLTs, the CCG will facilitate 4 PLT s a year as a whole North Durham event to engage with Practices to take forward the Primary Care strategy. Driving IT development 1. Set up an IT steering group including a NECS lead on IT development and identify SystmOne lead, EMIS lead and Community services representation. 2. To ensure 100% sign up to new GPSOC agreement by December 2015 3. The current 4 priorities within the National System implementation plan have now been technically implemented across 100% of Practices. These are: a. Patient Online b. GP2GP c. Summary Care Record d. Electronic transfer of Prescriptions (EPS2)
4. Next steps are to map utilization of these functions and to encourage greater use and reduce variation across Practices.. 5. Strong IT GP leadership has already seen the development of shared templates and recall systems across SystmOne Practices and community staff. Similar leadership needs to be identified for EMIS Practices so both can work together on sharing best Practice of the two systems 6. To identify priorities going forward including: a. Work on specific IT solutions to enable 7 day working, joined up working in delivering the Frail elderly strategy, and the new Diabetic model. b. Enabling Cross System accessibility to allow for Cross practice working and single input data entry for Community staff. c. Improve mobile capability d. Enable remote consultation and conferencing 7. Drive increasing use of GP teamnet as an information management tool for Practices. (See Quality Improvement Scheme) Develop an Estates strategy that aligns with existing and developing services 1. Review existing work with NHS Property Services. including the 6 facet survey of Practices and Community Estate in each Locality. 2. Work with Federations on a potential operating model/ service strategy in each Locality. 3. Define Estates requirements in each Locality, including best use of existing space 4. Explore opportunities for accessing funding for Estates development through centrally funded Primary Care Infrastructure Fund ( 250 million) 5. Deal with new applications for funding as they arise, and identify criteria for making Premises investment decisions.
Next steps Implementation of this strategy represents a challenging project agenda of transformational change that will require: 1. Engagement, communication and ownership with Practices and patients 2. Agreement of the new models of delivery of care in each Locality. 3. Support towards the organisational development of Federations, including ownership and engagement of the Primary Care Strategy as part of their Business Plans. 4. Creating effective commissioning models, new contracts and incentives to make it happen. Dr Jon Levick Director Primary Care Development and Innovation North Durham CCG